10 Ways to Safely Push Ketamine in the ED
A doctor recently took me on a ketamine trip, and I enjoyed it immensely.
So why is ketamine earning a spot in the general ED now? Here are 10 ways to ketamine can be used safely, lightly remixed from Strayer's presentation and with information from Howard Mell, MD, MPH, and Graham Walker, MD.
1. Push Ketamine for Analgesia
2. Consider Ketamine for Procedural Sedation
Strayer's ketamine pros are complete analgesia, sedation, and amnesia. Ketamine maintains airway reflexes and augments cardiorespiratory tone. "It's really a wonder drug for procedural sedation," Strayer said: It provides rapid onset, predictable duration, can be used intramuscularly, and has an unmatched margin of safety.
3. Reach For Ketamine in Rapid Sequence Induction (RSI)
Because ketamine has bronchodilation properties, Strayer recommended ketamine for patients being intubated for asthma or COPD. He also prefers ketamine as the RSI induction agent in all hypotensive patients, including trauma versus etomidate. It's Strayers "agent of choice" because it can be used in all patients where increase in heart rate and blood pressure is acceptable. "Dose big," said Strayer. He advised docs to take advantage of the long flat part at the end of the dose response curve.
4. Dilate in Asthma
5. Sedate Post-Intubation
An under-sedated intubated patient is a dangerous situation. In this case, push ketamine, not vecuronium, says Strayer. Choose ketamine when RSI isn't the right SI, and when you don't want paralysis.
6. Keep It Handy as a Tranquilizer
Speed, safety, reliability, and intramuscular dosing are Strayer's top reasons to reach for ketamine to tranquilize patients, as discussed in the ACEP Excited Delirium Task Force.
He added that doctors need to weigh ketamine's risk of increased heart rate and blood pressure (see #8) against dangers to staff and nearby patients if using it to sedate someone having an uncontrolled thrashing rage. This is equivalent to procedural sedation – so treat patients as such. They should have one-to-one nursing or a physician at bedside. Strayer recommended ketamine 500 mg IM x 1.
7. Manage Ketamine's Psychiatric Distress
The psychiatric distress caused by ketamine is not dangerous, says Strayer. Prevent it by pre-induction comfort and pre-induction coaching. Tell them the drug will give them very vivid dreams, but they can control it. He recommended suggestions such as, "Imagine that you are on a beach." Anticipate any distress and be careful with small doses. Eventually, patients just need to metabolize the drug. Strayer added that docs can use propofol to manage hypertension, which is better than ketofol.
8. Remember the Cardiac Factor
9. Lock it Down: Prevent Abuse
Afraid of ketamine dependency? Ketamine is not euphoric like opiates, Strayer said. It makes patients feel kind of weird, so people less likely to turn into addicts. Mell mentioned that he has staff double the number of inventory checks for ketamine, to prevent diversion, and also includes supervisors in the protocols.
10. Limit Risks of Laryngospasm, Hypertonicity, Hypersalivation
Laryngospasm is less common in adults than children but can happen. Anyone receiving dissociative-dose ketamine should be monitored as a procedural sedation patient. Strayer said physicians should respond with positive pressure ventilation, paralyze the patient, and intubate. Other possible side effects include hypertonicity, and hypersalivation. Also, there's no reversal agent.
Here's Strayer's guide to what happens at different doses of ketamine:
| Dose | Phase/Purpose | Response |
| 10-20 mg (0.1-0.3 mg/kg) | Analgesia | ABCs no problem. Second line to opiates, setup a ketamine drip for fine tuning. |
| 30 mg (0.2-0.5 mg/kg) | Recreational | Patient converses, walks, and follows directions, but is stoned. Psychiatric distress unlikely. |
| 50 mg (0.4-0.8 mg/kg) | Partial Dissociation/AVOID | Patients have some consciousness, some awareness, barely feel connected to the world and their own bodies. Might be able to speak or move. Most will find it terrifying, sometimes they freak out. This is where your patient should not be. |
| 100 mg (>0.7 mg/kg) | Dissociated/Intubate and Tranquilizer | Unaware, awake but unconscious -- this is the "K-hole." Patient feels nothing, forms no memories. |
| 1000 mg | Still dissociated/Still Safe | Higher doses do not intensify affect, just prolong the duration, suggesting a "remarkable margin of safety." |
Bonus: In recent years, researchers have debunked a swirl of myths surrounding ketamine. Strayer dug up studies that address alleged contraindications [1234567].
Strayer, Mell, and Walker disclosed no relevant relationships with industry.
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